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Critical Care Reviews Newsletter

October 7th 2012





Welcome to the 44th Critical Care Reviews Newsletter, bringing you the best critical care research published in the past week, plus a wide range of free full text review articles and guidelines from over 300 clinical and scientific journals.

This week's research studies include a comparison of prasugrel and clopidogrel in non-revascularized acute coronary syndrome, reduced catheter related infections with the use of chlorhexidine impregnated dressings, an intriguing suggestion that non-clinical transfer of critically ill patients is associated with prolonged ICU and hospital stay and a RCT demonstrating efficacy of eicosapentaenoic acid in reducing cerebral vasospasm and related infarction in subarachnoid haemorrhage. There are 2 new guidelines and about 20 free review articles on a wide range of topics.

The topic for This Week's Papers is the first of a multi-part series on critical care controversies, starting with a paper from a group of paediatricians calling for a moratorium on cardiocirculatory death in tomorrow's Paper of the Day. These papers are stimulating and should challenge mainstream beliefs.

The new CPD / CME facility has finally gone live. The UK Royal College of Anaesthetist don't actually approve external non-RCoA CPD/CME work but are happy to accept external certficates as prove of CPD/CME activity for revalidation purposes. These quizzes are mapped to the RCoA CPD matrix. There are two quizzes currently available and I'll try to add a new one each week. Check them out here.



New England Journal of Medicine:     Acute Coronary Syndrome

In 7243 patients with acute coronary syndrome not treated with revascularization, Roe et al compared prasugrel (10 mg daily) with clopidogrel (75 mg daily) in a double-blind, randomized trial. At 17 months there was no difference in the primary end point of death from cardiovascular causes, myocardial infarction, or stroke (prasugrel: 13.9% vs clopidogrel: 16.0%; prasugrel hazard ratio 0.91; 95% CI: 0.79 to 1.05; P=0.21).  A prespecified analysis of multiple recurrent ischemic events (all components of the primary end point) suggested a lower risk for prasugrel among patients under the age of 75 years (hazard ratio, 0.85; 95% CI, 0.72 to 1.00; P=0.04). Rates of intracranial bleeding and nonhemorrhagic serious adverse events were similar in the two groups, although there was a higher frequency of heart failure in the clopidogrel group. 

Abstract:  Roe. Prasugrel versus Clopidogrel for Acute Coronary Syndromes without Revascularization (The TRILOGY ACS Study). N Engl J Med 2012; 367:1297-1309


American Journal of Respiratory and Critical Care Medicine:     Catheter-Related Infections

Timsit et al performed an assessor-blinded randomized trial in 1879 patients with vascular catheters (4163 catheters, 34,339 catheter-days) comparing chlorhexidine dressings, highly adhesive dressings, and standard dressings on rates of catheter-related infections and catheter detachment.   The chlorhexidine dressings were associated with a 67% lower rate of major catheter-related infections (0.7/1000 vs. 2.1/1000 catheter-days; hazard ratio [HR], 0.328; 95% CI: 0.174-0.619 P=0.0006) and a 60% lower rate of catheter-related blood stream infections  (0.5/1000 vs. 1.3/1000 catheter-days; HR, 0.402; 95% CI, 0.186-0.868, P=0.02) than with non-chlorhexidine dressings. Decreases were noted in catheter colonization and skin colonization rates at catheter removal. The contact dermatitis rate was 1.1% with and 0.29% without chlorhexidine. Highly adhesive dressings decreased the detachment rate to 64.3% vs. 71.9% (P<0.0001) and the number of dressings per catheter to 2 (1-4) vs. 3 (1-5) (P<0.0001) but increased skin colonization (P<0.0001) and catheter colonization (HR=1.650; 95%CI, 1.21-2.26; P=0.0016) without influencing CRI or CR-BSI rates.

Abstract:  Timsit. Randomized Controlled Trial of Chlorhexidine Dressing and Highly Adhesive Dressing for Preventing Catheter-Related Infections in Critically Ill Adults. Am J Respir Crit Care Med epublished 4 October 2012


Critical Care:     Non-Clinical Patient Transfer

Barratt et al performed a propensity-matched cohort analysis comparing critical care patients who underwent a non-clinical, critical care unit to unit transfer to another hospital with those who were not transferred. Of 308,323 patients admitted to one of 198 adult general critical care units in England and Wales 759 patients underwent a non-clinical transfer within 48 hours of admission to the unit and were compared with 1518 propensity matched patients who were not transferred. There was no difference in the risk of ICU mortality or relative risk of ultimate acute hospital mortality was 1.01 (95% CI 0.87 to 1.16) for the non-clinical transfer group. Transferred patients received on average three additional days of critical care (p <0.001) with the difference in length of acute hospital stay being of borderline significance (p=0.05).

Full Text: Barratt. Effect of non-clinical inter-hospital critical care unit to unit transfer of critically ill patients: a propensity-matched cohort analysis. Critical Care 2012;16:R179


Journal of Anesthesia:     Atrial Fibrillation

Khalil et al prospectively compared amiodarone (n=219; IV loading dose of 5 mg/kg followed by an infusion of 15 mg/kg for 48 h postoperatively) with magnesium sulfate (n=219, IV loading dose 80 mg/kg over 30 min preoperatively followed by an IV infusion of 8 mg/kg/h for 48 h) in patients undergoing lobectomy. These two groups were compared with a control group of 219 patients who were analyzed retrospectively. Both amiodarone (n=21, 10 %) and magnesium sulphate (n=27, 12.5%) therapy were associated with reduced incidence of AF in comparison with the control group (n=44, 20.5 %) (p<0.05), although there was no difference in AF rates between the two active prophylactic agent. Also, there were significant differences between the three groups concerning ICU and total hospital stays (P < 0.05).

Abstract:   Khalil. A comparative study between amiodarone and magnesium sulfate as antiarrhythmic agents for prophylaxis against atrial fibrillation following lobectomy. J Anesth 2012; epublished ahead of print


World Journal of Neurosurgery:     Subarachnoid Haemorrhage

As eicosapentaenoic acid inhibits vascular smooth muscle contraction in subarachnoid hemorrhage, and has been shown to reduce the occurrence of cerebral vasospasm after SAH onset in a prospective, non-randomized study, Yonda et al undertook a prospective, multicenter, randomized study to confirm the preventive effects of EPA on cerebral vasospasm in SAH. In 162 patients who underwent surgical clipping within 72 h of SAH onset, therapy of 2700 mg/day EPA from the day after surgery until day 30 (n=81) reduced the rate of symptomatic vasospasm (15% vs. 30%, P = 0.022) and cerebral infarction due to vasopasm (7% vs. 21%; P = 0.012) in comparison to the control group (n=81). Multivariate analysis revealed an adjusted odds ratio of 0.39 (95% CI, 0.17-0.89; P = 0.028) for symptomatic vasospasm inhibition by EPA and 0.27 (95% CI, 0.09-0.72; P = 0.012) for inhibition of vasospasm induced cerebral infarction.

Yoneda. A Prospective, Multi-Center, Randomized Study of the Efficacy of Eicosapentaenoic Acid for Cerebral Vasospasm: the EVAS Study. World Neurosurg 2012;epublished ahead of print


Trials:     STUDY PROTOCOL - Traumatic Brain Injury

Severe traumatic brain injury is associated with activation of the sympathetic nervous system, leading to catecholamine excess, hypertension, abnormal heart rate variability, and agitation, and potentially poor neuropsychological outcome. Propranolol and clonidine are centrally acting drugs that may decrease sympathetic outflow, brain edema, and agitation. The DASH after TBI study is an actively accruing, single-center, randomized, double-blinded, placebo-controlled, two-arm trial, comparing combined centrally acting sympatholytic drugs, propranolol (1 mg intravenously every 6 h for 7 days) plus clonidine (0.1 mg per tube every 12 h for 7 days), with, double placebo, within 48 h of severe TBI. The primary endpoint is reduction in plasma norepinephrine level as measured on day 8. Secondary endpoints include comprehensive plasma and urine catecholamine levels, heart rate variability, arrhythmia occurrence, infections, agitation measures using the Richmond Agitation-Sedation Scale and Agitated Behavior scale, medication use (anti-hypertensive, sedative, analgesic, and antipsychotic), coma-free days, ventilator-free days, length of stay, and mortality. Neuropsychological outcomes will be measured at hospital discharge and at 3 and 12 months.

 Full Text:  Patel. Decreasing adrenergic or sympathetic hyperactivity after severe traumatic brain injury using propranolol and clonidine (DASH After TBI Study): study protocol for a randomized controlled trial. Trials 2012,13:177



Lung India:     Pneumonia

Respiratory Care:     Humidification

Review - Clinical

Expert Reviews of Anti-Infective Therapy:     Sepsis Therapy


Swiss Medical Weekly:     Anticoagulant Therapy


Scientifica:     ST Elevation Myocardial Infarction


Scientifica:    Pulmonary Oedema


Scientifica:     Angiopoietin/Tie2


PLoS Pathogen:     Escherichia Coli


Journal of Trauma & Treatment:     Corticosteroid Insufficiency


Annals of Nutritional Metabolism:     Probiotics


Current Biomarker Findings:     Acute Kidney Injury


Journal of the American College of Cardiology:     Percutaneous Coronary Intervention


Annals of Cardiac Anesthesia:     Acute Kidney Injury


Annals of Cardiac Anesthesia:     Cardiac Trauma


Cleveland Clinic Journal of Medicine:     Cognitive Impairment


Journal of Cerebral Blood Flow & Metabolism:     Antithrombotics


Archives of Internal Medicine:     Lyme Disease


Annals of Cardiothoracic Surgery:     Aortic Aneurysm


Indian Journal of Medical Research:     Dengue


Review - Basic Science

Nature Reviews Gastroenterology and Hepatology


Review - Non-Clinical

Journal of The Scientific Society:     Open Access


General Interest

Journal of General Medicine:     Resuscitation


Neurology Now:     Medical Identity Theft



I hope you find these brief summaries and links useful.

Until next week